Turkey has the fifth most COVID-19 cases in the world and has now entered a nationwide lockdown. How did it get here? Kaya Genç reports from Istanbul.
On April 30, 2021, Turkey's Health Minister, Fahrettin Koca, announced that 394 people had died from COVID-19 in the country that day, the highest figure since the first case was reported in Turkey more than a year ago. Shared on the second day of a 17-day nationwide lockdown, Koca's figures exposed the precipitous state of Turkey's struggle to contain the pandemic. As of May 9, the total death toll was 43 029. Total case numbers had reached 5 031 332, the fifth highest in the world. How did Turkey get here?
Turkey reacted early to the potential for a pandemic. The Health Ministry established its Coronavirus Scientific Advisory Board as early as Jan 10, 2020, just 11 days after China announced the outbreak in Wuhan. A fortnight later, on Jan 24, 2020, the Ministry issued its Coronavirus Health Guide, which provides guidelines for health workers, and established another organisation to deal with the social aspects of managing the outbreak.
Professor Mustafa Necmi İlhan, the dean of the Medicine Faculty at Gazi University in the capital Ankara, is on one of the Health Ministry's advisory boards. “We already had an action plan for influenza, if not for coronavirus, which we have updated for the current pandemic”, he told The Lancet.
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By early March, Turkey announced it was free of COVID-19. On March 9, 2020, the Turkish Medical Association announced it was “good but also surprising” to learn the country had no cases while neighbouring Iran, with which it has a 534 km border, was reporting thousands of cases.
Turkey's first case was reported just after midnight on March 11, 2020, hours before WHO first described the outbreak of COVID-19 as a pandemic. One of the early concerns for Turkish authorities was Umrah, the pilgrimage Muslims make to Mecca, which sees thousands of Turkish people travel abroad. By March 23, 2020, about 11 000 Umrah pilgrims were quarantined on their arrival back to Turkey. The Government placed them in state-run dormitories in Ankara, Konya, and 11 other cities.
“At this point we didn't have many options”, İlhan said. “We didn't have the vaccine, so the only thing to do was to contain infections. For that we needed to cut contact. In March we began undertaking very tough precautions, including banning inter-city travel, closing barber shops, malls, and beauty salons. We were learning about the pandemic ourselves. We knew it was spreading, but not details of its progress.”
At this stage just one laboratory in the capital Ankara was authorised to test for COVID-19 cases. Kayıhan Pala, a professor of public health at Uludağ University in Bursa and a member of the COVID-19 monitoring board under the Turkish Medical Association, points to this as Turkey's first mistake.
“For all of Turkey we had just one laboratory run by the Health Ministry”, Pala told The Lancet. “Medical schools with PCR facilities should have been added to the testing effort. My own university faculty had been offering PCR tests for two decades. But we weren't authorised for COVID-19 testing. The same is true for more than 60 medical faculties in the country. Instead of focusing on testing or contact tracing, the Ministry focused on treating the disease.” In the beginning of March, new testing centres opened in Erzurum and Istanbul; others soon followed.
Contact tracing began 5 weeks after the first case was reported on March 11. By April, 2020, 4000 Turkish contact tracing teams were operating. Pala contends they had little success in spotting early cases of super-spreaders. On May 13, 2020, Koca told a BBC reporter that “the R0 rate has reached 16 in Istanbul at one point”. Around the same time, the Turkish Government made mask wearing mandatory and began sending each citizen five masks per week. The initial plan to disseminate masks through the postal system failed and the Ministry began distributing masks through pharmacies. Fines were introduced for those who refused to wear masks.
The crisis quickly worsened. On April 8, 2020, Hans Kluge, the Europe regional director of WHO announced that he was “worried” about Turkey's situation. On April 10, the numbers were so alarming (4747 new cases and 98 deaths) that 2 h before midnight, the government introduced nationwide curfews. At this stage, despite Koca's warning that “Istanbul had become the Wuhan of Turkey”, the country's contact tracing rate remained less than 1%.
Meanwhile, the low case numbers presented by the Health Ministry were causing scepticism. When Pala voiced concern and proclaimed there were “more cases than Turkey reported” on April 20, 2020, there was a backlash. The governor of Bursa applied to the public prosecutor to open a case against Pala. The case was later dropped, and 5 months after Pala's announcement, the Health Ministry admitted its figures had referred to patients who had COVID-19 symptoms but had excluded asymptomatic patients, confirming Pala's statement.
The April, 2020, nationwide curfews achieved their circuit-breaking role and on May 11, 2020, Turkey took its first steps to regain normality by opening shopping malls and beauty salons. But the situation was not under control. By May 13, 2020, the R0 rate was “5 in some cities”, according to Koca. As the tourism season neared, reported case numbers decreased, and a broader reopening was announced for June, 2020. This allowed large public gatherings to return to Turkish life: commemorations of those who died on the July 15, 2016, coup attempt and the reopening of Hagia Sophia as a mosque on July 24, 2020, brought many thousands of people together.
“Perhaps because they experienced it for the first time, our people thought the coronavirus was behind them”, İlhan said. “In early June people were more attentive to hygiene and wore masks. But in July and August and with the arrival of Eid al-Adha at the end of summer, things took a turn for the worse. Some people rushed to coastal towns. Before Eid al-Adha, most coronavirus cases were in big cities, like Istanbul, Ankara, Izmit, Konya, and Bursa. Now the virus spread all over Turkey.”
For public health experts such as Pala, the use of hydroxychloroquine was turning into another concern. “Despite reports that its use showed no benefit in treating COVID-19 cases…that emerged in June, 2020, hydroxychloroquine remained on the Health Ministry's coronavirus guide”, he said. The Health Ministry has since removed hydroxychloroquine from it's guidance.
On Aug 2, 2020, Koca announced “the first wave of coronavirus had hit the beaches”, as cases spread among people socialising in coastal towns. The statement was important but could not change the events that followed. “We had great difficulties in October and November”, İlhan said. “There was sadly resistance against our rules. Some people refused to wear masks and use medicines.” He contends that with people returning home from holidays in September, cases spiked first in Ankara and then in Istanbul in October. “By November we started having really tough times at hospitals. Our intensive care units were functioning on full capacity. We had to rotate patients in between departments.”
Deniz Odabaş, a member of the Health Ministry's scientific council, lists the infection prevention measures in retirement homes and prisons as successes in this period. By the end of December, 20 881 had died from COVID-19 in Turkey in 2020. 69% (14 511) of those deaths occurred between Sept 1 and Dec 30, 2020.
Turkey's vaccination campaign began in 2021. In December, 2020, Koca had calculated that Turkey needed “100 million doses in three months” and announced that the vaccination programme would begin on Dec 11, 2020. Soon afterwards, on Jan 13, 2021, CoronaVac had received approval for “urgent use”. 3 million doses had arrived and the vaccination programme began, a month later than announced.
“Despite their low immunity response, inactive vaccines are the best known vaccine technology, so they became our first choice”, said Odabaş. “Our scientific council was very influential and effective in designing the Health Ministry's vaccination plans. Our strategy was right. The only problem was disruptions in the supply process.”
By early February, 2021, there were encouraging signs. Among countries with populations of more than 10 million, Turkey's vaccination percentages in the first 23 days were an encouraging 3·04%, higher than Italy (2·06%), Spain (2·90%), the UK (2·36%), and the USA (2·69%).In March, 2021, as the B.1.1.7, B.1.351, and P.1 variants spread in Turkey, the government announced a reopening programme. On March 24, 2021, the governing AK Party held its General Congress in Ankara, and members from its 11 million base—around one in eight Turkish citizens—began rushing to the capital. Social media was full of videos of packed buses party members took from Anatolian towns. By late April, daily case numbers surged, surpassing 60 000.
“There were no quarantines required from foreign visitors”, says Pala, complicating the crisis. This lax attitude soon evolved into the so-called quarantine tourism. In May, 2021, The Times reported groups of tourists from Pakistan and other countries taking advantage of so-called tourism packages comprising 10 days in Istanbul in five-star hotels that remove the requirement of quarantines when passengers continue to travel on to the UK or other high-income countries after Turkey. The packages were priced at £1495, including airport transports and COVID-19 tests.
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Such ventures will not halt the spread of variants in Turkey. According to İlhan “nearly 85% of the current cases come from the variant”. “There is no city in Turkey where we don't see the Kent variant [B.1.1.7].” Koca also reported five cases of the B.1.617 variant in April, 2021.
The pace of the vaccination programme has slowed. Sinovac, the Beijing-based biopharmaceutical company, halted deliveries of 100 million CoronaVac doses it promised to send in May. By May 1, 2021, 14 weeks after the vaccination effort began, about 13 million citizens received their first doses. But the 16·5% single dose vaccination rate appears small when compared with figures in Israel (59·7%), the UK (51·2%), and the USA (43·6%). As the number of new cases peaked, Turkey's testing capacity dropped, from 61 028 on April 20, 2021, to 38 553 on April 25, 2021. The same week Koca announced the death toll figure of 394, he issued another alarming statement: “We'll have difficulties in providing vaccine over the next two months, but after that we expect a vaccine abundance.” Turkey had placed its new hopes in Sputnik V, Russia's first approved vaccine developed by the Gamaleya Institute. 50 million doses were ordered, and Koca said he expected to receive them “in the upcoming 6 months”. While its European neighbours prepared to lift restrictions, Turkey was in a precarious position by early May.
Sinovac's supply problem brought to the fore Turkish officials' earlier reticence about mRNA vaccines. “The Pfizer–BioNTech vaccine is known as ‘the German vaccine’ in Turkey and in fact people trust German technologies more than Chinese technologies here”, said Odabaş. “That Uğur Şahin and Özlem Türeci, the BioNTech founders, have Turkish roots, also warmed people to their vaccine. Still, since the mRNA technology is comparatively novel, people approached it reluctantly at the beginning. Its status as the preferred vaccine all over the world and in Europe, one that is widely used and providing good results, soon removed those doubts.”
The scientific community also began to question the effectiveness of CoronaVac. “Look at Chile”, said Pala, where CoronaVac is being used. “Their vaccination rates surpassed 40%, but there is little fall in case numbers.” Meanwhile there were reports of a serious shortage of intensive care beds in Ankara, Istanbul, Diyarbakir, Van, and Konya. “The comparative fall in summer was replaced by a serious rise in death numbers by November, 2020”, Pala said. Turkey's health workers were struggling. By Dec 10, 2020, 216 health workers had died of COVID-19, according to the Health Ministry; the Turkish Medical Association reports that number had risen to 362 by the end of March.
Pala said these developments show the fragility of Turkey's family physician system. “One family physician has around 3200 citizens on their list. For a quality service, that number should be around 1500. We can't expect a family physician to serve properly with so many patients some of whom don't live in their neighbourhood.”
As Turkey remains in lockdown, Pala fears a vicious cycle for the future. “There was mass migration before the current lockdown from big cities to small towns and holiday destinations. This will increase case numbers in Anatolia. When those people travel back to big cities, the variants will have infected the country as a whole. Even if the vaccination programme resumes in June, we'll see its results in mid-August. If the Indian variant already takes its toll by then, things may not go as planned.”
Odabaş is more optimistic, hoping the country will learn from the mistakes made in 2020. “We're quite experienced from the past year, regarding touristic venues. I predict that this year, with the emergence of variant viruses the touristic season will open later than the previous year.”
Meanwhile in Berlin, Turkey's Foreign Minister, Mevlüt Çavuşoğlu, has told his German counterpart, Heiko Maas, that the vaccination programme would now focus on Turkey's touristic towns: “We will vaccinate everyone that tourists may encounter by the end of May.” This could create the prospect of two parallel realities in Turkey: lockdowns for locals, fines for Turks breaking quarantines, and freedom for foreign travellers.
As for the “Turkish vaccine” that the government promised to deliver in early 2021, the wait continues. İlhan said “4 or 5 months” are needed for the production of the Turkish vaccine, which is entering phase 3 studies in May, 2021. “The number of active cases, according to my calculations, stands at 350 000”, İlhan said, “which means around 1 million people are living in isolation or under quarantine at the moment. There is still great risk and danger. People expect a magical wand to fix this situation once the lockdown ends. But this isn't how it works”.